Step 1: Allow the Patient to Tell Her Story

The initial question should be open ended: “How can I help you today?” “Tell me about your concerns.” Allow the patient to express her symptoms and to tell you the story of her pain. It is important to take note of her concerns and chief symptoms so that you can address all issues by the end of the visit. For instance, the patient may present complaining of LLQ abdominal pain, but her main concern is that it prevents her from enjoying intercourse. Once you have a list of her concerns, and understand her situation, you can begin questioning to explore each of her problems. The patient will feel that she is being heard and will make the rest of her visit more productive.

Step 2: Develop a Timeline

Understanding how the pain started or with what event the patient associates the start of her pain can lead to identifying the root cause and help formulate a pertinent differential diagnosis. Instead of asking “How long have you had your pain?” you can ask “How did your pain start?” or “Can you associate anything with the start of your pain?” These questions may reveal underlying conditions and the cause of her pain. For example, a patient who presents with generalized pelvic pain and dyspareunia notes that the pain first started after a cesarean section 3 years ago and that her pain is mostly on the right aspect of her prior Pfannenstiel incision. This may suggest that the patient has an ilioinguinal nerve entrapment or adhesions from her Pfannenstiel scar. Operative reports are useful for investigating pain that started after a surgery, paying close attention to procedure details, positioning, and complications. Another example is a patient who presents with pelvic pain and sensation of pelvic/vaginal pressure that started after a pregnancy. Understanding that pregnancies place patients at risk of developing pelvic congestion syndrome would lead clinicians to consider this diagnosis. Specific events are not pathognomonic for a condition, but they can help focus or rule out pertinent differential diagnoses (Table 3.1).

Another approach is asking “When did you first start experiencing pain?” Obtaining a history in a timeline/chronological fashion may reveal a sequence of events and evolution of symptoms that may help identify the components of her pain. For example, a patient with generalized pelvic pain notes that she has always had painful periods (endometriosis) and that she later developed urinary frequency and suprapubic pain (bladder pain syndrome). She now has pain with sitting and painful intercourse and bowel movements (hypertonic pelvic floor disorder). When symptoms are broken down into a timeline, it is easier to address and explore her symptomatology (Figure 3.1).

Figure 3.1 Pelvic pain timeline of a patient with endometriosis affecting multiple organ systems.

Step 3: Map Out the Pain

Localization of pain using a pain map can elicit important diagnostic clues to identify anatomical sources of pain and to differentiate visceral, somatic, and neuropathic origins. It may be difficult for patients to describe their pain and express the location of their pain using anatomical terms. Many patients may simple state “It hurts down there” or “I am having female pain.” A pain map is useful in helping patients point out the location of their pain. Have the patient draw out or shade in the areas where she is experiencing pain on a pain map (Figure 3.2). Encourage the patient to write out descriptors or color code if she is experiencing multiple different pains. The pain map is a helpful tool to focus the patient during the encounter. This map should be completed prior to the patient visit.

Figure 3.2 Pain map demonstrating a patient experiencing pudendal neuralgia on the left and ilioinguinal neuralgia on the right. Color-coding can help differentiated different pains based on quality or intensity.

Pain maps may reveal a pain pattern that is well localized, a viscerotome, a dermatome, or a combination of each. Well localized pain can be drawn as a dot or x to suggest a somatic source of pain. Shaded areas of the lower abdomen and umbilicus may correspond to referred pain from viscera. An outline may follow a specific dermatome, suggesting neuropathic pain. Usually, pain maps are not as straightforward because pelvic pain usually presents with many overlapping conditions. Nevertheless, a detailed pain map as in Figure 3.2 can be further explored with the patient to determine causes of pain.

Step 4: Know Your Triggers

Pelvic pain can occur in specific settings. These settings or triggers of the pain can help build a differential diagnosis. Patients whose pain is not constant should be evaluated for triggers by simply asking “When do you feel your pain?” The patient may reveal that her pain is felt when she sits, performs a specific physical activity, drinks coffee, or with intercourse. Pain with sitting that is relieved by standing is the hallmark symptom for pudendal neuralgia (Chapter 15). Stress is a very common trigger that usually indicates a pelvic floor disorder, bladder pain syndrome, or musculoskeletal pain. Dyspareunia is discussed separately in the text that follows.

Step 5: Factor It Out

Pelvic pain conditions may have corresponding alleviating and aggravating factors based on the type of pain the patient is experiencing. For instance, somatic pain, or musculoskeletal pain, is usually improved with rest and application of heat, while physical activity that utilizes the involved muscles worsens the pain. When pain is worsened by a physical activity, the muscles involved in that activity should be assessed. Neuropathic pain from peripheral nerve injuries often improves with cold and may be positional. In contrast, neuropathic pain is worsened by touch and the patient may avoid tight clothing or belts. Visceral pain may be aggravated by different foods (irritable bowel syndrome [IBS], interstitial cystitis/bladder pain syndrome [IC/BPS]) or menses (adenomyosis) and alleviated after completion of visceral function such as bladder emptying (IC/BPS) and bowel movement (IBS) (Table 3.2). One possible exception is pelvic congestion syndrome, which involves visceral pain that is positional. Patients with pelvic congestion syndrome have deep throbbing pain and a sensation of heaviness with standing that is alleviated with lying flat. This is thought to be from stasis of blood in incompetent dilated pelvic and gonadal veins (Chapter 10).

Associated symptoms can help determine contributing anatomy. Urinary frequency, urgency, and nocturia can help differentiate the urological origin of pain, while urinary hesitancy, the inability to void spontaneously, is associated with hypertonic pelvic floor disorders (Table 3.3).

Step 6: Does the Pain Cycle?

The menstrual cycle is often used to describe the timing of chronic pelvic pain. Cyclical pain can suggest gynecological conditions such as adenomyosis or endometriosis, especially if it is associated with heavy menstrual bleeding. However, during menses, pain may be secondary to musculoskeletal causes. In fact, “menstrual cramps” may be associated with spasms of the abdominal wall and pelvic floor muscles. This pain is usually felt across the pelvis and lower back, acting like a tight belt or vise. Uterine pain, on the other hand, is mostly throbbing midline pelvic pain or low back pain. Cyclical pain can be tracked with a calendar, thereby identifying pain with menses, before/after menses, and ovulation. For instance, pelvic congestion syndrome may present with worsening pain prior to menses that improves during menses. Nevertheless, it is important to note that a cyclical pattern of pain may be secondary to increased sensitivity to pain from sex steroids and not related to either endometriosis or adenomyosis. Women in the ovulatory phase demonstrate higher pain sensitivity than at other times during their cycle. Estrogenic cycles may play a role in the development of chronic pelvic pain [2]. Thus, urological and gastrointestinal sources of pain may also follow a cyclical pattern. For example, bladder pain syndrome can present as suprapubic pain that becomes worse during menses and thus may be mistaken for dysmenorrhea of uterine origin.